Venous Disorders

Venous Thrombosis
- Development of a thrombus that results in thickening of vein wall; can lead to embolization

Venous thrombosis can cause swelling and pain of the leg in

which it forms. Large clots can also break free and travel to
the heart and lungs, where they can cause cardiac arrest and
sometimes death. This is called pulmonary embolism.

Types
- Thrombophlebitis: thrombus associated with inflammation
- Phlebothrombus: thrombus without inflammation
- Phlebitis: vein inflammation associated with invasive procedures (e.g., placement of an intravenous [IV]
line)
- Deep-vein thrombophlebitis: more serious than superficial thrombophlebitis because of the risk for
pulmonary embolism

Risks Factors for Thrombus Formation

- Venous stasis resulting from varicose veins, heart failure, or immobility
- Hypercoagulability disorders
- Injury to venous wall caused by IV injections, fractures, trauma
- After surgery, particularly hip surgery and open prostate surgery
- Pregnancy
- Use of oral contraceptives

Phlebitis

Assessment
- Red, warm area radiating up extremity
- Pain and soreness
 - Swelling

Interventions
- Apply warm, moist soaks to dilate vein and promote circulation
- Monitor client for signs of complications (e.g., tissue necrosis, infection, pulmonary embolus)

Deep-Vein Thrombosis

Assessment
- Calf or groin tenderness or pain, with or without swelling
- Homans' sign
- Warm skin

Interventions
- Provide bed rest
- Elevate affected extremity above level of heart
- Avoid using knee gatch or pillow under knees
- Do not massage extremity
- Provide pneumatic-compression device or antiembolism stockings as prescribed to reduce venous stasis
and assist venous return of blood to heart
 - Administer intermittent or continuous warm, moist compresses
- Measure and record circumferences of thighs and calves
- Monitor client for shortness of breath and chest pain, which can indicate pulmonary emboli
- Administer thrombolytic therapy or anticoagulant therapy (heparin prevents enlargement of existing clot
and prevents formation of new clots)

Client Instructions
- Explain hazards of anticoagulation therapy to client
- Teach client to recognize signs and symptoms of bleeding
- Tell client to avoid prolonged sitting or standing, constrictive clothing, and crossing legs when seated
- Client should elevate legs for 10 to 20 minutes every few hours each day
- Help client plan progressive walking program
- Teach client to inspect legs for edema and measure circumference of legs
- Antiembolism stockings should be worn
- The client should not smoke
- Stress importance of follow-up physician visits and laboratory studies
- Advise client to obtain and wear a Medic-Alert bracelet

Venous Insufficiency
- Results from prolonged venous hypertension, which stretches veins and damages valves
- Resultant edema and venous stasis cause venous-stasis ulcers, swelling, and cellulitis
- Treatment focuses on decreasing edema, promoting venous return from affected extremity, and healing
existing ulcers
Assessment
- Stasis dermatitis, evidenced by discoloration along ankles and extending up to calf
- Edema
- Ulcer formation

Client Instructions
- Advise client to wear antiembolism stockings during day and evening as prescribed (should be put on
after client awakens, before he or she gets out of bed)
- Client should avoid prolonged sitting or standing, constrictive clothing, and crossing legs when seated
- Tell client to elevate legs for 10 to 20 minutes every few hours each day
- Legs should be elevated above level of heart when client is in bed
- Teach client to use intermittent sequential pneumatic-compression system, if prescribed; instruct client
to apply compression system twice daily for 1 hour, morning and evening

Wound Care

Unna Boot
- Dressing constructed of gauze moistened with zinc oxide; will be changed weekly (usually by the
physician)
- Wound is cleansed with normal saline solution before application of Unna boot; providone-iodine
(Betadine) and hydrogen peroxide are not used because they destroy granulation tissue
- The Unna boot, which is covered with an elastic wrap that hardens, promotes venous return and prevents
stasis
- Monitor client for signs of arterial occlusion caused by a too-tight Unna boot
- Keep tape off client's skin
Medications
- Apply topical agents to wound as prescribed to debride ulcer, eliminate necrotic tissue, and promote
healing
- When applying topical agents, apply an oil-based agent (e.g., petroleum jelly [Vaseline]) on surrounding
skin; because debriding agents can injure healthy tissue

Varicose Veins
- Distended, protruding veins that appear darkened and tortuous
- Vein walls weaken and dilate, and valves become incompetent

Assessment
- Pain in legs, with dull aching after standing
- Feeling of fullness in legs
- Ankle edema

Interventions
- Assist with Trendelenburg test (see table below)
- Advise client to wear antiembolism stockings and elevate legs as often as possible
- Client should avoid constrictive clothing and pressure on legs
- Prepare client for sclerotherapy or vein stripping
 Trendelenburg test
The Trendelenburg test involves lying down and
lifting one leg up in the air. The doctor uses a hand
or a tourniquet to temporarily block off the blood
flow in your veins. When you stand up again, the
doctor can watch your varicose veins refilling with
blood; this gives an indication of which part of the
leg veins have faulty valves.

Sclerotherapy
- Sclerosing solution is injected into vein, followed by application of pressure dressing
- Incision and drainage of trapped blood in sclerosed vein are performed 14 to 21 days after injection,
followed by application of pressure dressing for 12 to 18 hours

Vein Stripping
- Varicose veins are removed if they are larger than 4 mm in diameter or are in clusters
- Before surgery, assist physician in marking veins and evaluating pulses as a baseline for postoperative
comparison
- Maintain elastic (Ace) bandages on client's legs after surgery
- Monitor groin and leg for bleeding through elastic bandages
- Monitor leg for edema, warmth, color, and pulses
- Elevate legs above level of heart after surgery
- Instruct client to avoid dangling legs or sitting in chairs and to elevate legs when sitting
- Emphasize importance of wearing antiembolism stockings after bandage removal

Peripheral Arterial Disease

- A chronic disorder in which partial or total arterial occlusion deprives the legs of oxygen and nutrients

Assessment
- Intermittent claudication (muscle pain resulting from inadequate blood supply)
- Rest pain: numbness, burning, or aching in distal portion of legs that awakens client at night and is
relieved by placing extremity in a dependent position
- Lower-back or buttock discomfort
- Loss of hair and dry, scaly skin on legs
- Thickened toenails
- Skin of legs is cold and gray-blue
- Elevational pallor and dependent rubor in legs
- Decreased peripheral pulses (or absence of pulses)
- Signs of arterial ulcer formation on or between toes or on upper aspect of foot, characterized as painful
 - Blood pressure measurements at thigh, calf, and ankle are lower than brachial pressure (blood-pressure
readings in the thigh and calf are normally higher than those in the arms)

Interventions
- Assess pain
- Monitor extremities for color, motion and sensation, and pulses
- Obtain blood pressure
- Assess client for signs of ulcer formation or gangrene
- Help develop individualized exercise program, which is initiated gradually and slowly increased

Client Instructions
- Advise client to walk to point of claudication, stop and rest, then walk a little farther
- Instruct client to elevate feet while at rest but to refrain from elevating them above level of heart because
extreme elevation slows arterial blood flow to feet (in severe PAD, a client with edema may sleep with
affected limb hanging from bed or sit upright in a chair for comfort)
- Client should avoid crossing legs, avoid exposing extremities to cold (causes vasoconstriction), and
wear socks or insulated shoes for warmth at all times
- Warn client never to apply direct heat to limb (e.g., heating pad or hot water) because the decreased
sensitivity in the limb make it easier for client to sustain a burn
- Client should inspect skin of extremities daily and report signs of skin breakdown
- Advise client to avoid use of tobacco and caffeine because of their vasoconstrictive effects
- Educate client in use of hemorrheologic and antiplatelet medications as prescribed

Procedures to Improve Arterial Blood Flow

- Percutaneous transluminal angioplasty
- Laser-assisted angioplasty
- Atherectomy
- Bypass surgery (aortofemoral or femoral-popliteal)

Raynaud's Disease
- Vasospasm of arterioles and arteries of the arms and legs that causes constriction of cutaneous vessels
- Attacks, which are intermittent, occur with exposure to cold or stress
- Mainly affects fingers, toes, ears, and cheeks

Assessment
- Blanching of extremity followed by cyanosis during vasoconstriction
- Tissue reddens when vasospasm is relieved
- Numbness, tingling, and swelling in affected body part; affected body part feels cold on palpation

Interventions
- Monitor pulses
- Administer vasodilators
- Help client identify and avoid precipitating factors (e.g., cold and stress)
- Instruct client to avoid smoking
- Instruct client to wear warm clothing, socks, and gloves in cold weather
 - Advise client to avoid injuries to fingers and hands

Buerger's Disease (Thromboangiitis Obliterans

- Occlusive disease of median and small arteries and veins
- Distal arms and legs are most commonly affected

Assessment
- Intermittent claudication
- Ischemic pain in digits while client is at rest and aching pain that is more severe at night
- Sensation of cool, numbness, or tingling
- Diminished pulses in distal extremities
- Extremities are cool and red when dependent
- Development of ulcerations in extremities

Interventions
- Similar to those for Raynaud’s disease

Aortic Aneurysm
- Abnormal dilation of arterial wall caused by localized weakness and stretching of medial layer or wall of
artery
- May be located anywhere along abdominal aorta
- Goal of treatment is to limit progression of disease by modifying risk factors, controlling blood
pressure to prevent strain on aneurysm, recognizing symptoms early, and preventing rupture

Assessment

Thoracic
- Pain extends to neck, shoulders, lower back, or abdomen

Abdominal
- Prominent, pulsating mass in abdomen, at or above level of umbilicus
- Systolic bruit over aorta
- Tenderness on deep palpation
- Abdominal or lower-back pain

Rupturing Aneurysm
- Severe abdominal or back pain
- Lumbar pain radiating to flank and groin
- Hypotension
- Increased pulse rate
- Signs of shock

Interventions: Thoracic and Abdominal Aortic Aneurysms

- Monitor client’s vital signs
 - Obtain information regarding back or abdominal pain
- Check peripheral circulation, including pulses, temperature, and color
- Watch for signs of rupture

Nonsurgical Interventions
- Modify risk factors
- Instruct client in procedure for monitoring blood pressure
- Advise client of importance of regular physician visits to monitor size of aneurysm
- Tell client to notify physician immediately of severe back or abdominal pain, soreness over umbilicus,
sudden development of discoloration in extremities, or persistently increased blood pressure
- Instruct client with thoracic aneurysm to immediately report chest or back pain, shortness of breath,
difficulty swallowing, or hoarseness

Pharmacological Interventions
- Administer antihypertensives to maintain blood pressure within normal limits and to prevent strain on
aneurysm

Abdominal-Aneurysm Resection
- Surgical resection or excision of aneurysm; excised section is replaced with a graft that is sewn end-to-
end

Postoperative Interventions
- Monitor peripheral pulses distal to graft site
- Watch for signs of graft occlusion (e.g., changes in pulses, cool-to-cold extremities below graft, white or
blue extremities or flanks, severe pain, abdominal distention)
- Limit elevation of head of bed to 45 degrees to prevent flexion of graft

Thoracic-Aneurysm Repair
- Thoracotomy or median sternotomy approach is used to enter thoracic cavity
- Aneurysm is exposed and excised, and a graft or prosthesis is sewn onto aorta (cardiopulmonary bypass
may be necessary)

Postoperative Interventions
- Monitor chest tubes for increased chest drainage, which may indicate bleeding or separation at graft site
- Assess sensation and motion of all extremities and notify physician of deficits, which may be a result of
diminished blood supply during surgery

Embolectomy
Removal of an embolus from an artery with the use of a catheter

Preoperative Interventions
- Conduct a baseline vascular assessment
- Administer anticoagulants and thrombolytics
- Place a bed cradle on bed and avoid bumping or jarring bed
- Maintain extremity in slightly dependent position

Postoperative Interventions
- Monitor affected extremity’s color, temperature, and pulse
- Assess sensory and motor function of affected extremity
 - Watch for signs and symptoms of new thrombi or emboli
- Monitor client for complications of artery reperfusion (e.g., spasms, swelling of skeletal muscles)
- Initially restrict client to bed rest in semi-Fowler's position
- Place a bed cradle on bed
- Administer anticoagulants
- Instruct client to avoid prolonged sitting or crossing of legs when sitting, to elevate legs when sitting,
and to wear antiembolism stockings

Vena Cava Filter and Ligation of Inferior Vena Cava

Vena Cava Filter

Insertion of an intracaval filter (umbrella) that partially occludes inferior vena cava and traps emboli to prevent
pulmonary emboli

Ligation
Suturing or placing clips on inferior vena cava to prevent pulmonary emboli

Hypertension
- Prehypertension describes an individual with a systolic blood pressure between 120 and 139 mmHg or a
diastolic pressure between 80 and 89 mmHg
- In an individual older than 50 years, systolic pressure is more important than diastolic pressure with
regard to need for treatment
- Major risk factor for coronary, cerebral, renal, and peripheral vascular disease
- Initially asymptomatic
- Goals of treatment include reduction of blood pressure and prevention or lessening of organ damage
- Nonpharmacological approaches (e.g., lifestyle changes) may be initially prescribed, but if cannot be
decreased after a reasonable period (1 to 3 months), the client may require pharmacological treatment

Primary or Essential Hypertension

No known cause

Risk factors
- Aging
- Family history
- Black race, with higher prevalence in males
- Obesity
- Smoking
- Stress

Secondary Hypertension
Results from other disorders or conditions

Precipitating Disorders and Conditions

- Cardiovascular disorders
- Renal disorders
- Endocrine-system disorders
- Pregnancy
- Medications

Assessment
 - May be asymptomatic
- Headache
- Visual disturbances
- Dizziness
- Chest pain
- Tinnitus
- Flushed face
- Epistaxis

Interventions
- Obtain blood pressure two or more times on both arms with client supine and standing
- Compare blood pressure with earlier documentation
- Identify client’s current medication regimen
- Weigh client
- Evaluate dietary patterns and sodium intake
- Check for organ involvement

Nonpharmacological Interventions
- Weight reduction, if necessary
- Dietary sodium restriction
- Initiation of a regular exercise program
- Avoidance of smoking
- Relaxation techniques and biofeedback therapy
- Elimination of unnecessary medications that may contribute to hypertension

Pharmacological Interventions
- Medications will be prescribed on basis of individual’s needs
- Usually a single medication is prescribed and monitored for its effectiveness, then medications are
added to regimen until blood pressure is controlled
- Medications include diuretics, ß-blockers, calcium-channel blockers, and angiotensin-converting
enzyme inhibitors
- Compliance with medication therapy is always evaluated

Client Instructions
- Educate client on importance of compliance with treatment plan
- Describe disease process, explaining that symptoms usually do not develop until organs have sustained
damage
- Help client plan a regular exercise program, avoiding heavy lifting and isometric exercises
- Help client identify ways to reduce stress
- Educate client on how to incorporate relaxation techniques into the daily living
- Teach client technique for monitoring blood pressure and encourage client to maintain diary of blood-
pressure readings
- Stress importance of lifelong medication and need for follow-up treatment
- Educate client on dietary restrictions, which may include sodium, fat, calories, and cholesterol
- Teach client how to shop for and prepare low-sodium meals
- Teach client to read food labels and to bake, roast, or boil foods; avoid salt in preparation of foods; and
avoid using salt at table
- Teach client that fresh foods are best; client should avoid canned foods
- Tell client to contact physician if uncomfortable side effects occur but not to discontinue medication
- Stress importance of follow-up care